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      Management of unstable pertrochanteric fractures, evaluation of forgotten treatment options

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          Abstract

          Introduction: Unstable trochanteric fractures are challenging with a high rate of implant failure and re-operation. Cephalomedullary nails proved to be a rational management choice for these injuries, yet other management options have not been well assessed. The aim of this study was to compare the use of DHS with trochanteric stabilizing plate (TSP) and proximal femoral locked plate (PFLP) in unstable pertrochanteric fractures. Methods: This randomized controlled trial (RCT) included 40 patients (22 males, 18 females) with unstable pertrochanteric fractures (AO/OTA 31A2.2/A2.3). The patients were randomized into group 1 managed by DHS with TSP while group 2 was managed by PFLP. All patients were followed up for 1 year. Patients were assessed radiographically and clinically using Harris hip score (HHS) at 3, 6 and 12 months. Operative time, estimated blood loss and time to union were also compared. Results: The difference of intra-operative variables, including operative time and intra-operative blood loss, between both groups was statistically insignificant. Time to bony union was faster in the first group with a statistically significant P value ( p = 0.04). Functional outcome per HHS was significantly better in group 1 ( p < 0.01) and implant failure in group 1 occurred statistically lesser ( p < 0.01). Discussion: DHS with TSP appears to be a good option of management for unstable pertrochanteric fractures. In contrast, the use of PFLP in unstable pertrochanteric fractures in the elderly does not appear to be a good alternative.

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          Most cited references17

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          Lateral femoral wall thickness. A reliable predictor of post-operative lateral wall fracture in intertrochanteric fractures.

          Although the importance of lateral femoral wall integrity is increasingly being recognised in the treatment of intertrochanteric fracture, little attention has been put on the development of a secondary post-operative fracture of the lateral wall. Patients with post-operative fractures of the lateral wall were reported to have high rates of re-operation and complication. To date, no predictors of post-operative lateral wall fracture have been reported. In this study, we investigated the reliability of lateral wall thickness as a predictor of lateral wall fracture after dynamic hip screw (DHS) implantation. A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures who received internal fixation with a DHS between January 2003 and May 2012 were reviewed. There were 103 men and 150 women with a mean age at operation of 78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected in 97 patients and the left side in 111. Clinical information including age, gender, side, fracture classification, tip-apex distance, follow-up time, lateral wall thickness and outcome were recorded and used in the statistical analysis. Fracture classification and lateral wall thickness significantly contributed to post-operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm. To our knowledge, this is the first study to investigate the risk factors of post-operative lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone.
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            The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures.

            Y Gotfried (2004)
            Pertrochanteric hip fractures still are a major orthopaedic challenge, and those that are unstable have the poorest prognosis. Fracture collapse is one of the postoperative complications reported in association with these fractures. My objective was to evaluate possible causes for pertrochanteric hip fracture collapse. Twenty-four patients with documented postoperative fracture collapse were evaluated retrospectively. The findings showed unequivocally that in all patients, this complication followed fracture of the lateral wall and resulted in protracted period of disability until fracture healing. The importance of the integrity of the lateral wall for event-free fracture healing clearly is indicated, and fracture of the lateral wall should be avoided in any fixation procedure. The presence of the lateral wall on the preoperative radiograph should be a major factor in determining the internal fixation device used for fracture stabilization. In unstable pertrochanteric hip fractures, the traditional description of the posteromedial fracture part as the most important prognostic factor should be revised to include the structural description of the lateral wall. Special caution should be taken when drilling at the base of this often delicate structure.
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              What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix?

              Intertrochanteric (IT) fractures pose a tremendous burden to the healthcare system. Although consistently good results are obtained while treating stable IT fractures, treatment failure rates with unstable fractures are much higher, and hence, it is imperative to identify unstable patterns. Presently, the conventionally classified unstable configurations (fracture with posteromedial comminution, reverse oblique, IT with subtrochanteric extension) and the recently added fracture patterns (IT fractures with avulsed greater trochanter and lateral wall breach) qualify as unstable IT fractures; however, the list is certainly not exhaustive. Disruption of lateral wall converts an IT fracture into a reverse oblique fracture equivalent and should be given a strong consideration in the decision matrix.
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                Author and article information

                Journal
                SICOT J
                SICOT J
                sicotj
                SICOT-J
                EDP Sciences
                2426-8887
                2020
                24 June 2020
                : 6
                : ( publisher-idID: sicotj/2020/01 )
                : 21
                Affiliations
                [1 ] Department of Orthopaedic and Trauma Surgery, Faculty of Medicine, Cairo University Cairo Egypt
                Author notes
                [* ]Corresponding author: amrhosny70@ 123456gmail.com
                Author information
                http://orcid.org/0000-0002-0174-6934
                Article
                sicotj200001 10.1051/sicotj/2020020
                10.1051/sicotj/2020020
                7313392
                32579105
                6a8a0ed5-ca5f-4eb0-ab71-2bfd9918625e
                © The Authors, published by EDP Sciences, 2019

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 31 December 2019
                : 02 June 2020
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 19, Pages: 7
                Categories
                Hip
                Original Article

                unstable pertrochanteric fracture,hip fractures,elderly,dynamic hip screw dhs,trochanteric stabilization plate tsp,proximal femoral locked plate pflp

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